Provider First Line Business Practice Location Address:
570 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83274-1470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-357-0473
Provider Business Practice Location Address Fax Number:
208-357-0498
Provider Enumeration Date:
02/22/2007